| NPI | 1801211628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: DC 1223G0001X) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN1001488) |
| Enumeration Date | 2014-03-03 |
| Last Update Date | 2018-05-16 |