| NPI | 1811488588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 10999) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 10083) |
| Enumeration Date | 2018-05-29 |
| Last Update Date | 2022-10-10 |