| NPI | 1962516054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 6096) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12235) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2017-04-07 |