| NPI | 1790764546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 7618) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 3968) |
| Enumeration Date | 2006-01-11 |
| Last Update Date | 2017-04-20 |