| NPI | 1710059605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: SD D0922) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MN D11766) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2010-08-03 |