| NPI | 1396124442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KS 61525) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058367) |
| 122300000X Dentist (Licence: MD 15628) | |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2019-07-23 |