| NPI | 1578445839 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 11476) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO 00206040) |
| Enumeration Date | 2025-07-25 |
| Last Update Date | 2026-06-22 |