| NPI | 1154848455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00203761) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D009859) |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2019-08-01 |