| NPI | 1700926227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8511) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS031317L) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2017-03-03 |