| NPI | 1023662335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416550) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0401416550) |
| Enumeration Date | 2019-07-25 |
| Last Update Date | 2023-04-03 |