| 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 |