| NPI | 1962797191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 010493) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NH 03892) |
| Enumeration Date | 2011-06-15 |
| Last Update Date | 2016-09-19 |