| NPI | 1538696703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12473) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 9128) |
| Enumeration Date | 2017-05-17 |
| Last Update Date | 2024-04-02 |