| NPI | 1790720720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI WI-5060) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 7771) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2007-07-08 |