| NPI | 1710967591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO 9510) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-3739) |
| Enumeration Date | 2006-01-18 |
| Last Update Date | 2007-09-18 |