| NPI | 1700065653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9411) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412507) |
| 1223G0001X Dentist, General Practice (Licence: SC 7000) | |
| Enumeration Date | 2007-10-29 |
| Last Update Date | 2020-01-18 |