| NPI | 1609195619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN014135) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2009015911) |
| Enumeration Date | 2010-06-01 |
| Last Update Date | 2010-09-17 |