| NPI | 1801058599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 202438) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SD DO816) |
| Enumeration Date | 2008-06-25 |
| Last Update Date | 2015-08-10 |