| NPI | 1700253911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D009696) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 64684) |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2017-05-04 |