| NPI | 1790356012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011191) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 17485) |
| 122300000X Dentist (Licence: VA 0401417735) | |
| Enumeration Date | 2021-07-07 |
| Last Update Date | 2024-06-24 |