| NPI | 1861473092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 8692) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 6501820-9923) |
| 1223G0001X Dentist, General Practice (Licence: ID D-4113) | |
| Enumeration Date | 2005-11-05 |
| Last Update Date | 2014-11-06 |