| NPI | 1457917767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17754) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 17754) |
| 1223G0001X Dentist, General Practice (Licence: PA DS042051) | |
| Enumeration Date | 2019-05-13 |
| Last Update Date | 2025-05-28 |