| NPI | 1083094551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN014948) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1001065-15) |
| 122300000X Dentist (Licence: OH 30.026213) | |
| Enumeration Date | 2015-05-31 |
| Last Update Date | 2022-01-25 |