| NPI | 1720078405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ND 1893) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN 10958) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2007-07-08 |