| NPI | 1750010237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 14649) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 38422) |
| 122300000X Dentist (Licence: FL 28479) | |
| Enumeration Date | 2022-06-09 |
| Last Update Date | 2026-07-07 |