| NPI | 1871517961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ 6557) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401410930) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2019-06-11 |