| NPI | 1669858718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 10829) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN DS0000010071) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2020-08-01 |