| NPI | 1982915567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 0025634) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D008310) |
| Enumeration Date | 2010-06-29 |
| Last Update Date | 2011-09-28 |