| NPI | 1699110775 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039531) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2013018051) |
| Enumeration Date | 2013-05-02 |
| Last Update Date | 2016-08-04 |