| NPI | 1912974213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ND 1816) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN 10645) |
| Enumeration Date | 2006-03-06 |
| Last Update Date | 2017-03-28 |