| NPI | 1164104923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 14654) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: SC 11524) |
| Enumeration Date | 2023-08-02 |
| Last Update Date | 2026-07-16 |