| NPI | 1255028072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SD D1499) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 41755) |
| Enumeration Date | 2023-04-20 |
| Last Update Date | 2025-08-28 |