| NPI | 1629186804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16067) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS036965) |
| Enumeration Date | 2006-08-28 |
| Last Update Date | 2022-12-13 |