| NPI | 1750991246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D010987) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 11295) |
| 122300000X Dentist (Licence: WA DE61155866) | |
| 122300000X Dentist (Licence: TX 38111) | |
| Enumeration Date | 2020-08-09 |
| Last Update Date | 2022-03-09 |