| NPI | 1720685761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601183) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401417191) |
| Enumeration Date | 2020-10-02 |
| Last Update Date | 2023-01-03 |