| NPI | 1497304844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416737) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17107) |
| Enumeration Date | 2019-09-09 |
| Last Update Date | 2021-12-08 |