| NPI | 1225706930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122464) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN122464.) |
| Enumeration Date | 2021-08-30 |
| Last Update Date | 2021-08-30 |