| NPI | 1104829761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AR 3240) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2010040599) |
| 122300000X Dentist (Licence: AR 3240) | |
| Enumeration Date | 2005-05-27 |
| Last Update Date | 2024-07-16 |