| NPI | 1821373325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: SD D1040) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: UT 8063149-9921) |
| Enumeration Date | 2011-10-15 |
| Last Update Date | 2015-05-05 |