| NPI | 1629163555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 8767233-8906) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 6860) |
| 122300000X Dentist (Licence: NV 3477) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2014-08-05 |