| NPI | 1770935876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AL 6317) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AL 6317) |
| Enumeration Date | 2016-07-13 |
| Last Update Date | 2019-06-07 |