| NPI | 1760467476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AK 1241) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: KY 7680) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2009-10-05 |