| NPI | 1750712097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 122300000X) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 7365) |
| Enumeration Date | 2013-12-12 |
| Last Update Date | 2013-12-12 |