| NPI | 1710020599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: SC 9312) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC 5349) |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2023-05-03 |