| NPI | 1831148303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ 6752) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D7162) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2007-07-08 |