| NPI | 1043967342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: CO 00205129) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00205129) |
| Enumeration Date | 2022-03-07 |
| Last Update Date | 2023-08-21 |