| NPI | 1255765574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12418) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 17473) |
| Enumeration Date | 2013-08-22 |
| Last Update Date | 2024-05-24 |