| NPI | 1720598659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 12087) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10529939-9921) |
| Enumeration Date | 2017-10-05 |
| Last Update Date | 2021-09-22 |