| NPI | 1760054779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17493) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 17493) |
| Enumeration Date | 2021-07-11 |
| Last Update Date | 2024-07-02 |