| NPI | 1720648454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00206131) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858304) |
| Enumeration Date | 2019-06-14 |
| Last Update Date | 2025-06-19 |