| NPI | 1407333024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 11363) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203644) |
| Enumeration Date | 2018-07-26 |
| Last Update Date | 2025-07-10 |