| NPI | 1962507079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA 9398) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL 8918) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2016-07-20 |