| NPI | 1164072823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN24311) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DRPM2031) |
| 1223G0001X Dentist, General Practice (Licence: FL DRPM2031) | |
| Enumeration Date | 2019-09-16 |
| Last Update Date | 2020-07-03 |