| NPI | 1326189846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 7730183-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2009033935) |
| 1223G0001X Dentist, General Practice (Licence: CO 9196) | |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2022-12-15 |