| NPI | 1396345963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DB-2023-0092) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00204532) |
| 1223G0001X Dentist, General Practice (Licence: NV 7425T) | |
| Enumeration Date | 2020-10-31 |
| Last Update Date | 2023-10-01 |