| NPI | 1679293617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MD 17760) |
| Additional Taxonomies | 126800000X Dental Assistant |
| Enumeration Date | 2022-08-30 |
| Last Update Date | 2022-10-06 |