| NPI | 1750730644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 9862879-9922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 00203308) |
| Enumeration Date | 2016-06-10 |
| Last Update Date | 2018-08-15 |