| NPI | 1679128201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 11589) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 11589) |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2023-03-15 |