| NPI | 1174154397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 012352) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00204073) |
| Enumeration Date | 2020-01-27 |
| Last Update Date | 2025-09-25 |