| NPI | 1760406706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WV 2571) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 84) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2018-07-02 |