| NPI | 1164881116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4853) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D010615) |
| Enumeration Date | 2016-02-18 |
| Last Update Date | 2023-05-16 |