| NPI | 1245625425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TN 10042) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 10042) |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2023-08-16 |