| NPI | 1205121662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11658) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 6954) |
| Enumeration Date | 2011-06-14 |
| Last Update Date | 2026-08-11 |