| NPI | 1063816163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401416353) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL12425) |
| Enumeration Date | 2014-10-17 |
| Last Update Date | 2023-10-14 |