| NPI | 1639220114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8928) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN 1000516) |
| 122300000X Dentist (Licence: PR 2707) | |
| Enumeration Date | 2007-01-13 |
| Last Update Date | 2013-08-09 |