| NPI | 1306153150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 19191) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR 11916) |
| Enumeration Date | 2010-08-31 |
| Last Update Date | 2023-12-14 |