| NPI | 1952774374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00202881) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13622) |
| Enumeration Date | 2015-11-06 |
| Last Update Date | 2016-08-23 |