| NPI | 1497564991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 18885) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901602423) |
| Enumeration Date | 2024-12-31 |
| Last Update Date | 2025-10-17 |