| NPI | 1073005476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 38112) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001841-15) |
| Enumeration Date | 2018-05-31 |
| Last Update Date | 2022-12-28 |