| NPI | 1013782077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401419305) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN2000422) |
| Enumeration Date | 2023-11-20 |
| Last Update Date | 2025-03-11 |