| NPI | 1114587987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 9780) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN24113) |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2021-03-31 |