| NPI | 1649363110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS-025176-L) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS-025176-L) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2019-06-07 |