| NPI | 1740668342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NE 7223) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-09182) |
| Enumeration Date | 2015-05-14 |
| Last Update Date | 2021-01-28 |