| NPI | 1679924625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00203057) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1001326-15) |
| Enumeration Date | 2016-06-30 |
| Last Update Date | 2017-03-27 |