| NPI | 1902881741 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MD 14243) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 28400) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2007-09-14 |