| NPI | 1811943798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 4418) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 7933) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2020-02-10 |