| NPI | 1790352755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MO 2021019495) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KS 61991) |
| Enumeration Date | 2021-06-08 |
| Last Update Date | 2022-10-19 |