| NPI | 1548644511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN22441) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058543) |
| Enumeration Date | 2015-07-19 |
| Last Update Date | 2021-02-19 |