| NPI | 1750453320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA 7710) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: GA DH003455) |
| 124Q00000X Dental Hygienist (Licence: GA DH004597) | |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2007-07-08 |