| NPI | 1679677876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 11235) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25855) |
| Enumeration Date | 2006-09-11 |
| Last Update Date | 2019-08-13 |