| NPI | 1861805947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KS 61013) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2014016796) |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2014-07-10 |