| NPI | 1619235082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4469-PE) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2011008123) |
| Enumeration Date | 2012-04-24 |
| Last Update Date | 2026-03-03 |