| NPI | 1083068811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WV 4426) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9889) |
| Enumeration Date | 2016-04-18 |
| Last Update Date | 2022-03-30 |