| NPI | 1760021075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TN 11812) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS042526) |
| Enumeration Date | 2020-01-03 |
| Last Update Date | 2022-02-28 |