| NPI | 1417784190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 0288) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 0288) |
| 1223P0700X Dentist, Prosthodontics (Licence: NC 0288) | |
| Enumeration Date | 2024-09-17 |
| Last Update Date | 2025-07-29 |