| NPI | 1740916725 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL 27187) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10829) |
| 1223G0001X Dentist, General Practice (Licence: KY 10829) | |
| Enumeration Date | 2022-08-01 |
| Last Update Date | 2025-10-19 |