| NPI | 1740698992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-09114) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1000974-15) |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2019-05-06 |