| NPI | 1679619373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 09065) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 20940) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2018-10-24 |