| NPI | 1700875077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MT DEN-DEN-LIC-24480) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN 10035MN) |
| Enumeration Date | 2005-10-19 |
| Last Update Date | 2025-10-01 |