| NPI | 1740689173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 11123723) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00202288) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2020-01-31 |