| NPI | 1184311524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00206691) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY D-00272) |
| Enumeration Date | 2023-04-18 |
| Last Update Date | 2026-09-08 |