| NPI | 1659770840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202274) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D009805) |
| Enumeration Date | 2014-08-14 |
| Last Update Date | 2018-03-19 |