| NPI | 1134565807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123363) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856246) |
| Enumeration Date | 2013-05-21 |
| Last Update Date | 2024-05-10 |