| NPI | 1609250752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: VA 0401414958) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401414958) |
| Enumeration Date | 2015-07-17 |
| Last Update Date | 2025-07-15 |