| NPI | 1306575105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00205173) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 00205173) |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2025-05-14 |