| NPI | 1770682460 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 8546) | 
| Additional Taxonomies | 122300000X Dentist (Licence: FL 8546) | 
| Enumeration Date | 2006-09-21 | 
| Last Update Date | 2025-09-11 |