| NPI | 1932339520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 09617) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401416720) |
| 122300000X Dentist (Licence: PA DS036939) | |
| 1223P0300X Dentist, Periodontics (Licence: PA DS036939) | |
| Enumeration Date | 2009-07-17 |
| Last Update Date | 2020-02-05 |