| NPI | 1649797861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00204142) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4785) |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2020-06-24 |