| NPI | 1669968202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CO 203676) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00203676) |
| Enumeration Date | 2018-07-06 |
| Last Update Date | 2022-11-07 |