| NPI | 1811019086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401007345) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15305) |
| Enumeration Date | 2007-04-06 |
| Last Update Date | 2018-07-05 |