| NPI | 1104984582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DE G1-0001367) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS-035668) |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2023-11-20 |