| NPI | 1669630430 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA Pending) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA Pending) |
| Enumeration Date | 2008-05-29 |
| Last Update Date | 2008-05-29 |