| NPI | 1205405628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 40329) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401418108) |
| 1223G0001X Dentist, General Practice (Licence: NJ 22DR03615) | |
| Enumeration Date | 2021-06-21 |
| Last Update Date | 2025-04-21 |