| NPI | 1013317171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 7281-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13956) |
| 1223G0001X Dentist General Practice (Licence: SC 9208) | |
| Enumeration Date | 2014-08-26 |
| Last Update Date | 2021-01-20 |