| NPI | 1790994606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: GA DN014297) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 3409) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2013-02-19 |