| NPI | 1891884235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 16850) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 4874) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2018-01-31 |