| NPI | 1114164340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: SC 9868) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 10493) |
| Enumeration Date | 2009-01-09 |
| Last Update Date | 2022-12-22 |