| NPI | 1316477524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: IL 019.031142) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.031142) |
| Enumeration Date | 2017-06-20 |
| Last Update Date | 2023-08-21 |