| NPI | 1053930289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123865) |
| Additional Taxonomies | 122300000X Dentist (Licence: MT DEN-DEN-LIC-21395) |
| Enumeration Date | 2020-04-08 |
| Last Update Date | 2025-07-21 |