| NPI | 1740530393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1001176) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15172) |
| Enumeration Date | 2012-09-11 |
| Last Update Date | 2018-05-11 |