| NPI | 1811202179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 10499) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ 8012) |
| Enumeration Date | 2010-08-11 |
| Last Update Date | 2012-01-23 |