| NPI | 1912109372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: FL DN18350) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS029739L) |
| Enumeration Date | 2007-06-05 |
| Last Update Date | 2017-04-12 |