| NPI | 1568929792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL 24395) |
| Enumeration Date | 2019-02-24 |
| Last Update Date | 2020-08-31 |