| NPI | 1770932808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AR 4095) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 32331) |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2018-03-20 |