| NPI | 1679574966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: VA 0401004979) |
| Additional Taxonomies | 291U00000X Clinical Medical Laboratory (Licence: VA 49D1041147) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2015-08-18 |