| NPI | 1972659035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: CT 6903) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 6903) |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2016-02-15 |