| NPI | 1619328424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202889) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00202889) |
| Enumeration Date | 2016-06-23 |
| Last Update Date | 2018-06-21 |