| NPI | 1801026273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: SC 11313) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25516) |
| 1223G0001X Dentist, General Practice (Licence: CA 58476) | |
| Enumeration Date | 2009-07-20 |
| Last Update Date | 2026-06-19 |