| NPI | 1578083465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1541) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NE 7397) |
| Enumeration Date | 2017-06-22 |
| Last Update Date | 2021-02-03 |