| NPI | 1477120749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 12331002-9921) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401419908) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0438000561) | |
| Enumeration Date | 2021-06-07 |
| Last Update Date | 2026-07-18 |