| NPI | 1801201645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2014041731) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 61003) |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2017-03-13 |