| NPI | 1053190009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 40046) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601907) |
| Enumeration Date | 2023-09-27 |
| Last Update Date | 2025-01-07 |