| NPI | 1285067249 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 8273) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 10585) |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2024-12-10 |