| NPI | 1679053987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401417830) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 34529) |
| 1223G0001X Dentist, General Practice (Licence: TX 34529) | |
| Enumeration Date | 2018-08-16 |
| Last Update Date | 2022-06-28 |