| NPI | 1760442909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 23816) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 4619T) |
| 1223G0001X Dentist, General Practice (Licence: NJ 22DI02044900) | |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2010-10-02 |