| NPI | 1538166939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D6471) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: TN DS0000011708) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2025-04-08 |