| NPI | 1962592121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00203792) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 18801) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2020-05-15 |