| NPI | 1063108801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 11179) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 13791) |
| Enumeration Date | 2023-04-14 |
| Last Update Date | 2026-07-21 |