| NPI | 1689075301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS039879) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 057553) |
| Enumeration Date | 2014-09-12 |
| Last Update Date | 2022-01-08 |