| NPI | 1609866292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D9065) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD3441) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2020-03-05 |