| NPI | 1013569573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 11530) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC 11530) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2019-07-15 |