| NPI | 1235973801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 40484) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D012702) |
| Enumeration Date | 2024-06-19 |
| Last Update Date | 2026-02-18 |