| NPI | 1588650097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12041) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 1817) |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2021-10-22 |