| NPI | 1205495074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11395) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401416518) |
| Enumeration Date | 2019-06-06 |
| Last Update Date | 2021-12-05 |