| NPI | 1255657441 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125Q00000X Oral Medicinist (Licence: NC 00175) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 00175) |
| 1223G0001X Dentist, General Practice (Licence: NC 00175) | |
| 125Q00000X Oral Medicinist (Licence: NC 0175) | |
| Enumeration Date | 2010-04-13 |
| Last Update Date | 2020-06-25 |