| NPI | 1760224299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 41349) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D15083) |
| Enumeration Date | 2024-06-06 |
| Last Update Date | 2025-07-18 |