| NPI | 1629063672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 6680) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 13695) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2011-09-27 |