| NPI | 1669731014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS038985) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401413592) |
| Enumeration Date | 2012-05-04 |
| Last Update Date | 2012-06-04 |