| NPI | 1780203174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401417042) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD Student) |
| Enumeration Date | 2020-04-15 |
| Last Update Date | 2021-09-23 |