| NPI | 1629126487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 9179) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WV 3703) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2011-12-01 |