| NPI | 1114536240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN00206183) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN24910) |
| Enumeration Date | 2020-07-24 |
| Last Update Date | 2025-04-21 |