| NPI | 1023157468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 014727) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: MO 014727) |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2021-03-15 |