| NPI | 1174062095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D010686) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-4918) |
| Enumeration Date | 2017-02-13 |
| Last Update Date | 2021-06-22 |