| NPI | 1306375704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00204872) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6949) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2021-10-11 |