| NPI | 1265172605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401417938) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-04-01 |
| Last Update Date | 2023-08-31 |