| NPI | 1700467511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00205358) |
| Additional Taxonomies | 122300000X Dentist (Licence: AR 4572) |
| Enumeration Date | 2021-04-14 |
| Last Update Date | 2023-04-27 |