| NPI | 1518315597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 09740) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2016017391) |
| Enumeration Date | 2016-05-31 |
| Last Update Date | 2023-01-27 |