| NPI | 1669853065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12650) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10587) |
| Enumeration Date | 2015-06-11 |
| Last Update Date | 2022-08-12 |