| NPI | 1699763755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039364) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV 3563) |
| 122300000X Dentist (Licence: SC 4245) | |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2013-06-21 |