| NPI | 1679029904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401416089) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9838416-9921) |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2021-08-10 |