| NPI | 1578975397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D4606) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6713) |
| 122300000X Dentist (Licence: UT 90837729922) | |
| Enumeration Date | 2014-05-28 |
| Last Update Date | 2023-06-22 |