| NPI | 1700771169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN123965) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: MA DH100628) |
| Enumeration Date | 2025-06-09 |
| Last Update Date | 2025-09-26 |