| NPI | 1558173567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY D-00240) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00206202) |
| Enumeration Date | 2025-01-25 |
| Last Update Date | 2026-06-11 |