| NPI | 1275086936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401417241) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040990) |
| Enumeration Date | 2016-07-29 |
| Last Update Date | 2021-01-26 |