| NPI | 1699188599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16187) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS040097) |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2023-01-04 |