| NPI | 1649568445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202814) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2011019937) |
| Enumeration Date | 2011-07-13 |
| Last Update Date | 2018-07-05 |