| NPI | 1700587391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 8072) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 14008927-9926) |
| Enumeration Date | 2023-03-13 |
| Last Update Date | 2025-12-12 |