| NPI | 1508212515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11789) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 059086) |
| Enumeration Date | 2016-05-09 |
| Last Update Date | 2024-05-22 |