| NPI | 1902847643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS038218) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN15414) |
| 1223G0001X Dentist, General Practice (Licence: MA 16061) | |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2014-12-02 |