| NPI | 1619939584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 2845) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 17345) |
| 1223G0001X Dentist, General Practice (Licence: IA 06681) | |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2007-07-08 |