| NPI | 1861550998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID 4885) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PR 2717) |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2018-03-17 |