| NPI | 1780702274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ DO4830) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D4830) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2011-07-27 |