| NPI | 1154733087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 10842) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MD 15506) |
| 1223G0001X Dentist General Practice (Licence: PA DS040270) | |
| Enumeration Date | 2014-05-27 |
| Last Update Date | 2021-11-16 |