| NPI | 1780803361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 6072) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D11374) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2007-07-08 |