| NPI | 1679098008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID 5167) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2017028241) |
| 1223G0001X Dentist, General Practice (Licence: ID D5167) | |
| Enumeration Date | 2017-08-07 |
| Last Update Date | 2025-04-30 |