| NPI | 1689950503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2025023621) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3690) |
| Enumeration Date | 2011-10-24 |
| Last Update Date | 2025-08-01 |