| NPI | 1619257581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN20349) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN20349) |
| 1223P0700X Dentist, Prosthodontics (Licence: FL DN20349) | |
| Enumeration Date | 2011-08-24 |
| Last Update Date | 2022-01-14 |