| NPI | 1104939438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD5425) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D5306) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2023-02-22 |