| NPI | 1154595718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN011804) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA 11808) |
| Enumeration Date | 2008-04-15 |
| Last Update Date | 2023-04-06 |