| NPI | 1710338314 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-09975) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: RI LD00127) |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2022-12-16 |