| NPI | 1861801490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN21058) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1000980) |
| Enumeration Date | 2014-08-07 |
| Last Update Date | 2015-10-12 |