| NPI | 1104893049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 1456639922) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 1456639922) |
| Enumeration Date | 2006-02-28 |
| Last Update Date | 2023-07-20 |