| NPI | 1306299565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0438000494) |
| Additional Taxonomies | 122300000X Dentist (Licence: AL 6338) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401418669) | |
| Enumeration Date | 2016-07-22 |
| Last Update Date | 2026-05-07 |