| NPI | 1255641536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1001171) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25106) |
| Enumeration Date | 2010-10-20 |
| Last Update Date | 2022-07-21 |