| NPI | 1164065157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416766) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17191) |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2019-12-09 |