| NPI | 1710969845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 8137) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD2272) |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2013-08-12 |