| NPI | 1619329448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 6906659) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00203138) |
| Enumeration Date | 2016-07-05 |
| Last Update Date | 2019-01-08 |