| NPI | 1154947349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122833) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858696) |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2023-06-29 |