| NPI | 1639813298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12898) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2022-04-20 |
| Last Update Date | 2022-07-30 |