| NPI | 1720460207 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00205956) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 058740) |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2025-01-04 |