| NPI | 1306418975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14591) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002637-15) |
| 122300000X Dentist (Licence: GA DN122462) | |
| Enumeration Date | 2021-07-13 |
| Last Update Date | 2026-04-17 |