| NPI | 1649290065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 4712015) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 2177035) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2007-07-08 |