| NPI | 1720117039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD1562) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D3755) |
| Enumeration Date | 2007-03-04 |
| Last Update Date | 2007-07-08 |