| NPI | 1154586311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DE G1-0001345) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS037813) |
| Enumeration Date | 2008-07-26 |
| Last Update Date | 2026-06-16 |