| NPI | 1477137974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: NC 12198) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 9239) |
| 1223P0300X Dentist Periodontics (Licence: SC 9239) | |
| Enumeration Date | 2021-05-11 |
| Last Update Date | 2022-07-11 |