| NPI | 1124487590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN122625) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 15814) |
| Enumeration Date | 2016-02-15 |
| Last Update Date | 2022-09-06 |