| NPI | 1720366412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 6168) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 32780) |
| Enumeration Date | 2011-07-28 |
| Last Update Date | 2018-03-17 |