| NPI | 1689171282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D14013) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 10295) |
| Enumeration Date | 2018-04-10 |
| Last Update Date | 2023-06-19 |