| NPI | 1609879550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 3376) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IL 019-019332) |
| Enumeration Date | 2005-05-24 |
| Last Update Date | 2007-08-27 |