| NPI | 1114656568 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 122300000X Dentist (Licence: TX 41120) | 
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2022020476) | 
| Enumeration Date | 2022-06-09 | 
| Last Update Date | 2025-06-16 |