| NPI | 1912349994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA Dn015742) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15473) |
| Enumeration Date | 2013-07-19 |
| Last Update Date | 2018-12-15 |