| NPI | 1669016796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WI 1002734) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 11173) |
| Enumeration Date | 2019-11-01 |
| Last Update Date | 2022-06-30 |