| NPI | 1972600955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D10631) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KY 7339) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2020-10-20 |