| NPI | 1619609153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS043750) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 13577) |
| Enumeration Date | 2022-06-24 |
| Last Update Date | 2026-03-04 |