| NPI | 1770786329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8391) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC 5618) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: NC 8391) | |
| Enumeration Date | 2007-06-08 |
| Last Update Date | 2018-10-04 |