| NPI | 1649339482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 5294) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 05444) |
| 1223G0001X Dentist, General Practice (Licence: MN D11415) | |
| Enumeration Date | 2006-12-07 |
| Last Update Date | 2007-07-08 |