| NPI | 1639130883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 7775) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 7775) |
| 122300000X Dentist (Licence: NC 7715) | |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2014-01-10 |