| NPI | 1164109336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601681) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6001237-15) |
| Enumeration Date | 2023-06-29 |
| Last Update Date | 2025-01-27 |