| NPI | 1780257451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1002857) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1002857) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2023-03-08 |