| NPI | 1699345611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205043) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417544) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2022-09-06 |