| NPI | 1225635857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 100245315) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 100245315) |
| Enumeration Date | 2020-10-06 |
| Last Update Date | 2024-05-12 |