| NPI | 1700829546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR 9432) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 6612) |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2018-03-17 |