| NPI | 1902172711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 8332) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 3896) |
| 1223G0001X Dentist, General Practice (Licence: KY 9151) | |
| Enumeration Date | 2012-03-26 |
| Last Update Date | 2014-04-29 |