| NPI | 1679097448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR d10770) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 6965) |
| Enumeration Date | 2017-08-02 |
| Last Update Date | 2022-07-21 |