| NPI | 1174252324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 7495) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601272) |
| 122300000X Dentist (Licence: LA 7495) | |
| Enumeration Date | 2022-06-05 |
| Last Update Date | 2024-07-17 |