| NPI | 1699194092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN21843) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty (Licence: FL DN21843) |
| Enumeration Date | 2014-04-14 |
| Last Update Date | 2020-03-24 |