| NPI | 1528443454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA DS042884) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0442000256) |
| Enumeration Date | 2015-07-21 |
| Last Update Date | 2021-05-17 |