| NPI | 1649759879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D11067) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4949) |
| Enumeration Date | 2018-08-08 |
| Last Update Date | 2025-06-10 |