| NPI | 1710069547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PR 2577) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 5631) |
| 1223P0300X Dentist, Periodontics (Licence: FL DN17276) | |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2014-11-03 |