| NPI | 1932196821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: PA 23118) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 15950) |
| Enumeration Date | 2005-10-05 |
| Last Update Date | 2007-07-08 |