| NPI | 1649525171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 11810) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28263) |
| Enumeration Date | 2012-07-20 |
| Last Update Date | 2017-06-07 |