| NPI | 1326555251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D11296) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 61291) |
| Enumeration Date | 2017-12-31 |
| Last Update Date | 2020-08-19 |