| NPI | 1174195457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00205087) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5637) |
| Enumeration Date | 2021-07-15 |
| Last Update Date | 2024-02-14 |