| NPI | 1629489901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16628) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: FL DH20333) |
| Enumeration Date | 2014-05-08 |
| Last Update Date | 2023-11-07 |