| NPI | 1588493530 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 122300000X Dentist (Licence: DE G9-0010553)  | 
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS045403)  | 
| Enumeration Date | 2024-07-29 | 
| Last Update Date | 2025-09-24 |