| NPI | 1801204375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2023028725) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058375) |
| 122300000X Dentist (Licence: KS 62032) | |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2023-10-11 |