| NPI | 1669021804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: LA 7384) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 35708) |
| 1223G0001X Dentist, General Practice (Licence: TX 35708) | |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2025-02-24 |