| NPI | 1801183371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WI 6770-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS038768) |
| Enumeration Date | 2011-07-06 |
| Last Update Date | 2020-02-26 |