| NPI | 1710960661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN014731) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV WV 2409) |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2022-07-21 |