| NPI | 1285360925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205237) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-07-26 |
| Last Update Date | 2022-07-26 |