| NPI | 1700515632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 12739) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 12739) |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2026-03-26 |