| NPI | 1760764518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD3766) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4376) |
| Enumeration Date | 2011-09-16 |
| Last Update Date | 2015-03-28 |