| NPI | 1376195800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AR 4477) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 35289) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2020-10-12 |