| NPI | 1740617992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2021016226) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4515) |
| Enumeration Date | 2013-10-02 |
| Last Update Date | 2022-04-21 |