| NPI | 1609986447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 4363) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD2449) |
| 1223G0001X Dentist, General Practice (Licence: AK 415) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2007-07-09 |