| NPI | 1902146954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: WA DE60856783) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 50 058325) |
| Enumeration Date | 2013-02-27 |
| Last Update Date | 2020-09-08 |