| NPI | 1871917799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CT 11357) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD UNKNOWN) |
| Enumeration Date | 2014-02-12 |
| Last Update Date | 2015-06-23 |