| NPI | 1053865410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KS 61999) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN015236) |
| Enumeration Date | 2016-08-15 |
| Last Update Date | 2023-03-21 |