| NPI | 1558987164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00204993) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D14376) |
| Enumeration Date | 2020-06-19 |
| Last Update Date | 2022-06-24 |