| NPI | 1861857633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA RFD000016) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415054) |
| Enumeration Date | 2015-12-22 |
| Last Update Date | 2015-12-22 |