| NPI | 1649790452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00203746) |
| Additional Taxonomies | 122300000X Dentist (Licence: ME DEN4569) |
| Enumeration Date | 2017-06-22 |
| Last Update Date | 2019-10-31 |