| NPI | 1962584565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2005026032) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019-026828) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2011-05-12 |