| NPI | 1760036891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17095) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN24564) |
| 122300000X Dentist (Licence: VA 0401416647) | |
| Enumeration Date | 2019-07-26 |
| Last Update Date | 2025-11-24 |