| NPI | 1104427418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122728) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 36786) |
| Enumeration Date | 2020-11-03 |
| Last Update Date | 2022-09-20 |