| NPI | 1376019760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 23841) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 23841) |
| 1223G0001X Dentist, General Practice (Licence: MD 16763) | |
| 1223G0001X Dentist, General Practice (Licence: VA 0401416428) | |
| Enumeration Date | 2018-10-23 |
| Last Update Date | 2024-10-02 |