| NPI | 1790743953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AL 6052) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24717) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2013-11-12 |