| NPI | 1609550169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 6001184) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: WI 6001184) |
| 261QM1300X Clinic/Center, Multi-Specialty (Licence: WI 6001184) | |
| Enumeration Date | 2023-06-14 |
| Last Update Date | 2026-05-13 |