| NPI | 1114542024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205753) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 12161) |
| Enumeration Date | 2020-06-16 |
| Last Update Date | 2023-10-03 |