| NPI | 1720217136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2009018129) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D008221) |
| Enumeration Date | 2009-07-07 |
| Last Update Date | 2016-11-11 |