| NPI | 1679614887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: DC 3198) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 6227) |
| 122300000X Dentist (Licence: VA 8166) | |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2007-07-08 |