| NPI | 1598253262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 10832973) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D1106) |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2024-12-04 |