| NPI | 1801929294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DE G1-0001204) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS-030059-L) |
| Enumeration Date | 2007-03-14 |
| Last Update Date | 2024-02-14 |