| NPI | 1508382474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS044824) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857669) |
| Enumeration Date | 2017-08-22 |
| Last Update Date | 2024-07-30 |