| NPI | 1043983174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D12091) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 37501) |
| Enumeration Date | 2021-07-26 |
| Last Update Date | 2025-06-03 |