| NPI | 1336979954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D12065) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D12065) |
| Enumeration Date | 2024-08-07 |
| Last Update Date | 2024-08-07 |