| NPI | 1912923475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM 2704) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 8164) |
| Enumeration Date | 2006-07-15 |
| Last Update Date | 2012-04-24 |