| NPI | 1629683925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2021010442) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN016113) |
| Enumeration Date | 2020-09-14 |
| Last Update Date | 2021-06-15 |