| NPI | 1609229103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TN 10250) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 10250) |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2023-08-22 |