| NPI | 1194818781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: LA 5240) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 5240) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2025-04-15 |