| NPI | 1235701913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN122529) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS043280) |
| Enumeration Date | 2021-07-13 |
| Last Update Date | 2022-06-21 |