| NPI | 1225304041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401414075) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 11065) |
| Enumeration Date | 2012-03-26 |
| Last Update Date | 2025-01-15 |