| NPI | 1265850754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10016) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2014006877) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2018-03-17 |