| NPI | 1508357161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MS 4076-19) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 6859) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2020-03-17 |