| NPI | 1801165667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 10401) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401007209) |
| Enumeration Date | 2011-12-23 |
| Last Update Date | 2011-12-23 |