| NPI | 1801080015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MT 2306) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9453) |
| Enumeration Date | 2007-08-30 |
| Last Update Date | 2011-08-11 |