| NPI | 1972678704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist Dentist Anesthesiologist (Licence: AZ D5819) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ 5819) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2016-06-30 |