| NPI | 1689695413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MS 305998) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM dd2726) |
| 122300000X Dentist (Licence: GA dn013268) | |
| 122300000X Dentist (Licence: NY 036708) | |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2011-07-13 |