| NPI | 1497128318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2020030615) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 102996) |
| Enumeration Date | 2015-11-02 |
| Last Update Date | 2023-12-04 |