| NPI | 1306391016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 10873) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 40161) |
| Enumeration Date | 2016-08-23 |
| Last Update Date | 2021-07-29 |