| NPI | 1902119720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NV S4-84) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8859) |
| Enumeration Date | 2010-07-21 |
| Last Update Date | 2013-09-03 |