| NPI | 1609556638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14998) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00205634) |
| Enumeration Date | 2023-07-24 |
| Last Update Date | 2023-08-16 |