| NPI | 1912207507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413715) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS038411) |
| Enumeration Date | 2010-10-28 |
| Last Update Date | 2012-12-12 |