| NPI | 1669879946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: WI 1001285-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039762) |
| Enumeration Date | 2014-12-02 |
| Last Update Date | 2022-07-21 |