| NPI | 1780612820 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD3063) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MD 13508) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2009-02-19 |