| NPI | 1730549551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901601554) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2022036996) |
| Enumeration Date | 2016-03-07 |
| Last Update Date | 2023-03-13 |