| NPI | 1548929821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61464733) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14834) |
| 122300000X Dentist (Licence: SD D1341) | |
| Enumeration Date | 2021-12-14 |
| Last Update Date | 2024-10-18 |