| NPI | 1053890855 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416411) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 11144) |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2020-02-12 |