| NPI | 1669970034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 9206) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10398139-9921) |
| Enumeration Date | 2018-01-31 |
| Last Update Date | 2018-08-14 |