| NPI | 1164937421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4823) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4823) |
| 1223G0001X Dentist, General Practice (Licence: CA 103623) | |
| Enumeration Date | 2017-12-08 |
| Last Update Date | 2022-11-02 |