| NPI | 1205345576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16627) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA DN1857772) |
| Enumeration Date | 2017-09-29 |
| Last Update Date | 2022-07-29 |