| NPI | 1922389410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60479537) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 055782) |
| Enumeration Date | 2011-08-29 |
| Last Update Date | 2020-04-17 |