| NPI | 1093370967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12261) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.032296) |
| 171000000X Military Health Care Provider (Licence: NC 12261) | |
| Enumeration Date | 2019-05-07 |
| Last Update Date | 2022-05-21 |