| NPI | 1114376225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001296) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.031419) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: IL 021.003126) | |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2024-01-26 |