| NPI | 1669809422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D4540) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ID D-4540) |
| Enumeration Date | 2013-10-10 |
| Last Update Date | 2022-07-21 |