| NPI | 1770835969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6001465) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2012-10-11 |
| Last Update Date | 2026-07-19 |