| NPI | 1063024370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO 205103) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WY 1555) |
| Enumeration Date | 2020-08-18 |
| Last Update Date | 2023-07-12 |