| NPI | 1619155207 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NV 5638) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ D008177) |
| Enumeration Date | 2008-02-05 |
| Last Update Date | 2016-04-01 |