| NPI | 1720391030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 15464) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 0025746) |
| 1223G0001X Dentist General Practice (Licence: WI 6630-15) | |
| Enumeration Date | 2010-07-16 |
| Last Update Date | 2018-12-21 |