| NPI | 1124754957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12910284-9926) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID 5581801) |
| Enumeration Date | 2022-07-25 |
| Last Update Date | 2026-08-12 |