| NPI | 1861629941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KY 9054) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9054) |
| Enumeration Date | 2009-06-16 |
| Last Update Date | 2012-08-09 |