| NPI | 1558330753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PR D1972) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 14229) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2023-08-01 |