| NPI | 1881612968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D009861) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 44346) |
| 1223G0001X Dentist, General Practice (Licence: AZ 9861) | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2019-09-11 |