| NPI | 1205277118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D10803) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VT 016.0096868) |
| Enumeration Date | 2013-07-09 |
| Last Update Date | 2021-03-22 |