| NPI | 1558937979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 38126) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14547) |
| Enumeration Date | 2021-05-27 |
| Last Update Date | 2022-08-05 |