| NPI | 1649780123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 7294) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 33197) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2022-04-06 |