| NPI | 1740517564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2013026080) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0025981) |
| Enumeration Date | 2009-11-16 |
| Last Update Date | 2014-05-19 |