| NPI | 1104502699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS014475) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS044175) |
| Enumeration Date | 2023-06-27 |
| Last Update Date | 2025-07-17 |