| NPI | 1669737631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1001122) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413691) |
| Enumeration Date | 2012-07-05 |
| Last Update Date | 2012-07-05 |