| NPI | 1164126348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO DEN.00205503) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 11854) |
| Enumeration Date | 2023-03-30 |
| Last Update Date | 2023-03-30 |