| NPI | 1578025706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 9511) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN015902) |
| Enumeration Date | 2019-04-05 |
| Last Update Date | 2019-12-18 |