| NPI | 1407659782 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KY 11174) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 11174) |
| Enumeration Date | 2025-03-31 |
| Last Update Date | 2025-08-06 |