| NPI | 1639392517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 5263) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CT 5263) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2014-08-26 |