| NPI | 1386167377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205436) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN 13894) |
| Enumeration Date | 2017-07-20 |
| Last Update Date | 2024-09-04 |