| NPI | 1629480363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9754) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 9754) |
| Enumeration Date | 2014-05-29 |
| Last Update Date | 2020-08-06 |