| NPI | 1700929320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA 6329) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 6329) |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2025-09-11 |