| NPI | 1356890081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61247820) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401416345) |
| 1223G0001X Dentist, General Practice (Licence: IL 019030965) | |
| 1223G0001X Dentist, General Practice (Licence: NY 000082) | |
| Enumeration Date | 2016-09-22 |
| Last Update Date | 2023-06-27 |