| NPI | 1053795112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NM dd4342) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD4342) |
| Enumeration Date | 2015-07-17 |
| Last Update Date | 2021-01-11 |