| NPI | 1205544293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PR 3553) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PR 3553) |
| Enumeration Date | 2022-11-09 |
| Last Update Date | 2025-03-25 |