| NPI | 1063082048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID 5281) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-5281) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2024-04-17 |