| NPI | 1609853654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WV 3118) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 7286) |
| 122300000X Dentist (Licence: WV 3118) | |
| 1223P0300X Dentist, Periodontics (Licence: NC 7286) | |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2018-06-29 |