| NPI | 1508440348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DRPM2744) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX ETN816) |
| Enumeration Date | 2021-05-07 |
| Last Update Date | 2024-06-12 |