| NPI | 1316561244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12164516-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-09752) |
| Enumeration Date | 2020-06-06 |
| Last Update Date | 2021-09-16 |