| NPI | 1245735166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL dn26555) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 060479) |
| Enumeration Date | 2018-03-25 |
| Last Update Date | 2022-01-05 |