| NPI | 1174109789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 38676) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 00000) |
| 122300000X Dentist (Licence: ID 5971582) | |
| Enumeration Date | 2021-03-23 |
| Last Update Date | 2026-01-06 |