| NPI | 1639528540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2019008752) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001346-15) |
| Enumeration Date | 2016-06-10 |
| Last Update Date | 2026-01-30 |