| NPI | 1639208093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 08507) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 5484-015) |
| Enumeration Date | 2007-03-03 |
| Last Update Date | 2007-11-02 |