| NPI | 1699984864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO 10145) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 6141) |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2010-07-14 |