| NPI | 1497325583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401417510) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA -0401417510) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2022-09-12 |