| NPI | 1912100652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 4295) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 150556) |
| 1223G0001X Dentist, General Practice (Licence: NC 8543) | |
| Enumeration Date | 2007-06-08 |
| Last Update Date | 2019-11-14 |