| NPI | 1053865758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MT 11639) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00202910) |
| Enumeration Date | 2016-08-10 |
| Last Update Date | 2018-07-13 |