| NPI | 1396353850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: SC 9559) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC 11871) |
| 124Q00000X Dental Hygienist (Licence: MA DH89933) | |
| Enumeration Date | 2020-07-20 |
| Last Update Date | 2020-07-20 |