| NPI | 1700809563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2018014802) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 19-026162) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2018-07-18 |