| NPI | 1790030898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D12185) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00201801) |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2025-07-22 |