| NPI | 1295203172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MD 16622) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC 1001895) |
| Enumeration Date | 2018-11-08 |
| Last Update Date | 2023-10-17 |