| NPI | 1801107057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 6433) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 26219) |
| Enumeration Date | 2010-06-23 |
| Last Update Date | 2014-06-19 |