| NPI | 1700983723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: GA DN013482) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 3953) |
| 1223P0300X Dentist, Periodontics (Licence: SC 0646) | |
| 122300000X Dentist (Licence: GA DN013482) | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2012-06-20 |