| NPI | 1700290483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: LA 6529) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 3760-14) |
| 1223G0001X Dentist, General Practice (Licence: MS 3760-14) | |
| Enumeration Date | 2014-06-20 |
| Last Update Date | 2021-08-16 |