| NPI | 1255595732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00202471) |
| Additional Taxonomies | 122300000X Dentist (Licence: AL 0005616) |
| Enumeration Date | 2008-07-15 |
| Last Update Date | 2026-02-23 |