| NPI | 1972625598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: GA DN015536) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 48089) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2019-07-12 |