| NPI | 1720631187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35457) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN24356) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401416812) | |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2025-06-26 |