| NPI | 1710476924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12605) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10867252-9921) |
| Enumeration Date | 2018-05-02 |
| Last Update Date | 2025-07-27 |