| NPI | 1467804583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12888079-8903) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D009512) |
| Enumeration Date | 2016-07-13 |
| Last Update Date | 2023-02-06 |