| NPI | 1720579865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12797) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10846612-9922) |
| Enumeration Date | 2018-05-24 |
| Last Update Date | 2024-07-03 |