| NPI | 1316670698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: ID 7571268) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: WY 1703) |
| Enumeration Date | 2022-07-05 |
| Last Update Date | 2025-07-30 |