| NPI | 1588236673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D11729) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D11729) |
| 1223G0001X Dentist, General Practice (Licence: UT 12363998-9922) | |
| Enumeration Date | 2021-07-16 |
| Last Update Date | 2023-01-10 |