| NPI | 1912909631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 4089) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 7598) |
| 1223P0300X Dentist, Periodontics (Licence: GA 12680) | |
| 1223P0300X Dentist, Periodontics (Licence: TN 8355) | |
| 1223P0300X Dentist, Periodontics (Licence: VA 0401411018) | |
| 1223P0300X Dentist, Periodontics (Licence: SC 612) | |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2007-09-11 |