| NPI | 1679892640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D009517) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 7684117-9922) |
| Enumeration Date | 2010-05-28 |
| Last Update Date | 2016-12-20 |