| NPI | 1679733547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ME DEN4362) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN013731) |
| Enumeration Date | 2008-06-13 |
| Last Update Date | 2014-08-25 |