| NPI | 1285200071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205543) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 09883) |
| Enumeration Date | 2021-06-02 |
| Last Update Date | 2023-06-26 |