| NPI | 1053002329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011767) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: UT 13659941-9926) |
| Enumeration Date | 2023-05-17 |
| Last Update Date | 2024-02-15 |