| NPI | 1568624690 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 6945665-9923) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 6945665-9923) |
| Enumeration Date | 2008-06-30 |
| Last Update Date | 2024-12-19 |