| NPI | 1245907641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD5514) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD5514) |
| Enumeration Date | 2021-08-24 |
| Last Update Date | 2023-07-18 |