| NPI | 1104302777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 34321) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 34321) |
| Enumeration Date | 2018-07-16 |
| Last Update Date | 2021-08-10 |