| NPI | 1659883759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 23085) |
| Additional Taxonomies | 122300000X Dentist (Licence: AL 6470) |
| 1223P0300X Dentist, Periodontics (Licence: FL DN23085) | |
| Enumeration Date | 2017-10-30 |
| Last Update Date | 2020-09-08 |