| NPI | 1679828040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202657) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3721) |
| Enumeration Date | 2012-07-20 |
| Last Update Date | 2015-11-21 |