| NPI | 1861717456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN009638) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA 122300000X) |
| Enumeration Date | 2010-04-07 |
| Last Update Date | 2010-04-07 |