| NPI | 1639512254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10019) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D10019) |
| 122300000X Dentist (Licence: NM TD-00-58) | |
| Enumeration Date | 2013-04-12 |
| Last Update Date | 2024-06-13 |