| NPI | 1992069298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D9868) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ID D-4450) |
| Enumeration Date | 2012-07-02 |
| Last Update Date | 2013-07-15 |