| NPI | 1750696480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 106322) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 0704) |
| Enumeration Date | 2010-08-18 |
| Last Update Date | 2010-08-18 |