| NPI | 1083105878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-09595) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.031889) |
| Enumeration Date | 2018-05-29 |
| Last Update Date | 2019-10-31 |