| NPI | 1659691921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401410355) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 12606) |
| Enumeration Date | 2010-06-09 |
| Last Update Date | 2010-06-09 |