| NPI | 1104565142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ D011386) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: UT 12863647-9923) |
| Enumeration Date | 2022-05-28 |
| Last Update Date | 2022-05-28 |