| NPI | 1023851540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MS 111342) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901602042) |
| Enumeration Date | 2024-06-13 |
| Last Update Date | 2025-07-13 |