| NPI | 1578721718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD3016) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9533) |
| 122300000X Dentist (Licence: ID D-4127) | |
| Enumeration Date | 2008-05-23 |
| Last Update Date | 2021-04-01 |