| NPI | 1790394740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D14660) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN25800) |
| 1223G0001X Dentist, General Practice (Licence: CA 111324) | |
| Enumeration Date | 2020-07-27 |
| Last Update Date | 2025-03-18 |