| NPI | 1063622835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ DO-8915) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NE 5539) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2025-11-04 |