| NPI | 1972706919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR 9064) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 6622694-9922) |
| Enumeration Date | 2007-06-07 |
| Last Update Date | 2015-07-15 |