| NPI | 1407474315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MD 18107) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401416988) |
| Enumeration Date | 2020-07-07 |
| Last Update Date | 2024-01-02 |