| NPI | 1710416458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2020002303) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS041288) |
| Enumeration Date | 2017-06-07 |
| Last Update Date | 2020-08-13 |