| NPI | 1154808517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 12552) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13997) |
| Enumeration Date | 2018-07-27 |
| Last Update Date | 2022-01-12 |