| NPI | 1710057211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID 4221) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR 5015) |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2012-06-20 |