| NPI | 1487029112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 202706) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 10069548-9922) |
| Enumeration Date | 2015-12-07 |
| Last Update Date | 2022-07-21 |