| NPI | 1679793392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL DN12252) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: FL DN12252) |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2018-11-23 |