| NPI | 1033594767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11272) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401414966) |
| Enumeration Date | 2015-07-23 |
| Last Update Date | 2020-08-22 |