| NPI | 1699746529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 5941796) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12167) |
| 1223G0001X Dentist, General Practice (Licence: CA 55319) | |
| Enumeration Date | 2006-01-30 |
| Last Update Date | 2012-03-13 |