| NPI | 1245708551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NV S4-115C) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 34644) |
| Enumeration Date | 2018-11-05 |
| Last Update Date | 2021-08-04 |