| NPI | 1659876852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D14692) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00203475) |
| 1223G0001X Dentist, General Practice (Licence: CO 00203475) | |
| Enumeration Date | 2018-03-28 |
| Last Update Date | 2022-03-10 |