| NPI | 1780688176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD5627) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 5811) |
| Enumeration Date | 2005-06-13 |
| Last Update Date | 2022-07-13 |