| NPI | 1790905800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2010033385) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 8632) |
| 1223G0001X Dentist, General Practice (Licence: KS 60918) | |
| Enumeration Date | 2007-04-30 |
| Last Update Date | 2014-06-05 |