| NPI | 1053691329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 09649) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 8259) |
| Enumeration Date | 2011-08-18 |
| Last Update Date | 2022-01-06 |