| NPI | 1902042641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: VA 0401413742) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 10400) |
| Enumeration Date | 2008-12-31 |
| Last Update Date | 2018-02-14 |