| NPI | 1619047578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00202335) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 4748608) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2014-10-15 |