| NPI | 1720086762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 8319) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 8319) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2019-05-16 |