| NPI | 1124695515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TN 11907) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 12254) |
| Enumeration Date | 2021-06-05 |
| Last Update Date | 2022-08-05 |