| NPI | 1710565148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122386) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN25818) |
| Enumeration Date | 2021-03-29 |
| Last Update Date | 2023-08-11 |