| NPI | 1265624332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D010196) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 6605138-9921) |
| Enumeration Date | 2007-08-13 |
| Last Update Date | 2026-08-14 |