| NPI | 1265882104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KS 61486) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MO 2016001210) |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2022-05-12 |