| NPI | 1710048202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6001684-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 009242) |
| 122300000X Dentist (Licence: AZ D009621) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2025-07-16 |