| NPI | 1720438716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4525) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 6695) |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2021-02-16 |