| NPI | 1609134790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 10740) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD3791) |
| Enumeration Date | 2012-04-26 |
| Last Update Date | 2015-09-16 |