| NPI | 1568147817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 134199219922) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 134199219922) |
| Enumeration Date | 2023-06-15 |
| Last Update Date | 2024-06-14 |