| NPI | 1700495991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00204457) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO T-DEN.00000053) |
| Enumeration Date | 2020-07-23 |
| Last Update Date | 2020-09-10 |