| NPI | 1316508468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 12390) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: DC 1002056) |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2021-07-20 |