| NPI | 1962400309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 12402) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 001751) |
| Enumeration Date | 2005-07-11 |
| Last Update Date | 2020-01-24 |