| NPI | 1558972083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1002218) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417266) |
| Enumeration Date | 2020-08-10 |
| Last Update Date | 2025-04-07 |