| NPI | 1619538436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: AZ D012024) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 7005) |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2025-07-14 |