| NPI | 1205453321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 25104) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 25104) |
| Enumeration Date | 2020-07-06 |
| Last Update Date | 2020-09-22 |