| NPI | 1639481849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 6544) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8987) |
| 1223E0200X Dentist, Endodontics (Licence: NC 6544) | |
| Enumeration Date | 2010-07-06 |
| Last Update Date | 2022-03-28 |