| NPI | 1104355585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415824) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041358) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2021-06-28 |