| NPI | 1265982482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MD 16351) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041068) |
| 122300000X Dentist (Licence: VA 0401415412) | |
| Enumeration Date | 2016-10-12 |
| Last Update Date | 2020-11-20 |