| NPI | 1659474013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 3872) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM 1682) |
| 1223G0001X Dentist, General Practice (Licence: SC 3681) | |
| Enumeration Date | 2006-09-07 |
| Last Update Date | 2007-07-08 |