| NPI | 1083607261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 4426) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 41851) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2026-05-12 |