| NPI | 1205358173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37099) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 3920-17) |
| 122300000X Dentist (Licence: AL 6435-C1) | |
| Enumeration Date | 2017-07-12 |
| Last Update Date | 2023-02-28 |