| NPI | 1588240766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: AZ D012474) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.0020505466) |
| Enumeration Date | 2021-03-19 |
| Last Update Date | 2025-08-19 |