| NPI | 1700193380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 9709) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 6934) |
| Enumeration Date | 2010-09-02 |
| Last Update Date | 2014-10-23 |