| NPI | 1255999264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35200) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN24136) |
| Enumeration Date | 2019-06-04 |
| Last Update Date | 2022-02-01 |