| NPI | 1629380936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 6140) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DL10985) |
| 122300000X Dentist (Licence: TX 28661) | |
| 122300000X Dentist (Licence: MA DN1855612) | |
| Enumeration Date | 2010-07-02 |
| Last Update Date | 2013-04-03 |