| NPI | 1639935646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: DC 30190326) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VA 40149351) |
| Enumeration Date | 2024-02-27 |
| Last Update Date | 2025-07-29 |