| NPI | 1053690644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 12720188-9924) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413223) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401413223) | |
| 1223G0001X Dentist, General Practice (Licence: WA DE 60745129) | |
| Enumeration Date | 2011-08-12 |
| Last Update Date | 2023-01-07 |