| NPI | 1275235129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401419972) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 13595) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2026-08-20 |