| NPI | 1609863554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ND 1653) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO DEN-105831) |
| 1223G0001X Dentist, General Practice (Licence: MN D9114) | |
| Enumeration Date | 2005-10-05 |
| Last Update Date | 2007-07-08 |