| NPI | 1619655578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 6001971) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401418257) |
| Enumeration Date | 2023-07-10 |
| Last Update Date | 2025-10-14 |