| NPI | 1528635497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NE 7722) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA DDS-09950) |
| Enumeration Date | 2021-06-08 |
| Last Update Date | 2022-04-25 |