| NPI | 1730278052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL 16390) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: FL DN16390) |
| 1223G0001X Dentist, General Practice (Licence: FL dn16390) | |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2022-08-12 |