| NPI | 1053000133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 14208085) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00206523) |
| Enumeration Date | 2023-05-03 |
| Last Update Date | 2026-01-20 |