| NPI | 1154702140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MD 16591) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: MD 16591) |
| 122300000X Dentist (Licence: MD 16591) | |
| Enumeration Date | 2015-06-15 |
| Last Update Date | 2026-07-14 |