| NPI | 1619954013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60030651) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 051469) |
| Enumeration Date | 2005-12-27 |
| Last Update Date | 2011-05-20 |