| NPI | 1790522993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2025021842) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401419104) |
| 122300000X Dentist (Licence: TX 40904) | |
| Enumeration Date | 2024-07-15 |
| Last Update Date | 2025-11-07 |