| NPI | 1891135968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: SC 8748) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039655) |
| Enumeration Date | 2013-07-03 |
| Last Update Date | 2016-07-05 |