| NPI | 1790366177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN25949) |
| Additional Taxonomies | 122300000X Dentist (Licence: NJ 22DI02862100) |
| Enumeration Date | 2021-04-18 |
| Last Update Date | 2024-01-07 |