| NPI | 1568080414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN2000225) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401417353) |
| Enumeration Date | 2020-07-08 |
| Last Update Date | 2023-01-22 |