| NPI | 1790127744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D008764) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 7134 - 15) |
| Enumeration Date | 2013-07-18 |
| Last Update Date | 2018-05-16 |