| NPI | 1801870928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401411416) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 411416) |
| 1223G0001X Dentist, General Practice (Licence: MA 20754) | |
| Enumeration Date | 2005-12-01 |
| Last Update Date | 2019-07-23 |