| NPI | 1205054202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR d6036) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D6036) |
| Enumeration Date | 2007-04-23 |
| Last Update Date | 2025-06-12 |