| NPI | 1790841765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD1926) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D3565) |
| 122300000X Dentist (Licence: UT 145124-9921) | |
| 122300000X Dentist (Licence: AK 759) | |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2010-05-20 |