| NPI | 1578136537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011122) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D011122) |
| Enumeration Date | 2021-07-19 |
| Last Update Date | 2026-06-25 |