| NPI | 1013403666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA ds042966) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203680) |
| Enumeration Date | 2018-07-06 |
| Last Update Date | 2022-01-28 |