| NPI | 1710265921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413238) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.028704) |
| Enumeration Date | 2011-07-22 |
| Last Update Date | 2012-03-03 |