| NPI | 1760896138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 9441831-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4097) |
| Enumeration Date | 2014-06-13 |
| Last Update Date | 2019-07-12 |