| NPI | 1750675419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WV 3945) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS038966) |
| Enumeration Date | 2011-05-30 |
| Last Update Date | 2014-02-24 |