| NPI | 1467804955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202934) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 3877-16) |
| 1223G0001X Dentist, General Practice (Licence: MS 3877-16) | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2023-12-07 |