| NPI | 1679566897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 16443) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1659G) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2007-07-08 |