| NPI | 1497487318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11762) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 38504) |
| 1223G0001X Dentist, General Practice (Licence: TX 38504) | |
| Enumeration Date | 2022-06-29 |
| Last Update Date | 2024-04-08 |