| NPI | 1962679050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 3818-015) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 3818-015) |
| Enumeration Date | 2008-05-08 |
| Last Update Date | 2014-01-21 |