| NPI | 1780767228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00008199) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 047151) |
| 122300000X Dentist (Licence: VA 41417) | |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2007-07-08 |