| NPI | 1063597474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 4259) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 2324) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2023-03-07 |