| NPI | 1720271752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AK 123971) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 56079) |
| Enumeration Date | 2007-08-22 |
| Last Update Date | 2018-10-16 |