| NPI | 1295517720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: NC 14353) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6001347-15) |
| Enumeration Date | 2023-10-18 |
| Last Update Date | 2025-08-29 |