| NPI | 1720080831 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401410942) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 13457) |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2016-01-29 |