| NPI | 1053815043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN25145) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DRP1811) |
| Enumeration Date | 2018-03-22 |
| Last Update Date | 2020-09-02 |