| NPI | 1396268504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 10679) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 10675) |
| 1223G0001X Dentist, General Practice (Licence: FL DN22824) | |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2025-10-23 |