| NPI | 1609964147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 4653) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: AZ 4653) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2019-04-29 |