| NPI | 1134375744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 7030242) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9803) |
| Enumeration Date | 2008-08-14 |
| Last Update Date | 2025-02-24 |