| NPI | 1558494344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 0024969) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 9371) |
| 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: TX 0024969) | |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2022-10-24 |