| NPI | 1366856510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11776) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 29907) |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2023-07-10 |