| NPI | 1376900795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10285) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024652) |
| 122300000X Dentist (Licence: SC 9736) | |
| 122300000X Dentist (Licence: GA DN122579) | |
| 122300000X Dentist (Licence: TN 12162) | |
| Enumeration Date | 2016-01-15 |
| Last Update Date | 2024-12-05 |