| NPI | 1568988186 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MI 2901022187) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022187) |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2024-11-12 |