| NPI | 1770081580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: FL 29508) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: FL RBT-18-50214) |
| Enumeration Date | 2018-01-26 |
| Last Update Date | 2024-08-09 |