| NPI | 1659063675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123755) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1859823) |
| Enumeration Date | 2023-05-26 |
| Last Update Date | 2026-04-21 |