| NPI | 1972586824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: WV 2753) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: WI 4785015) |
| 1223P0300X Dentist Periodontics (Licence: MD 7704) | |
| 1223G0001X Dentist General Practice | |
| 1223P0300X Dentist Periodontics | |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2007-07-08 |