| NPI | 1356080139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: LA 7319) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 7319) |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2025-08-26 |