| NPI | 1104310648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 10519) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00203455) |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2022-12-05 |