| NPI | 1548790629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2019045908) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 61410) |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2020-08-21 |