| NPI | 1770008575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA DDS-09530) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7398) |
| Enumeration Date | 2017-08-14 |
| Last Update Date | 2020-01-23 |