| NPI | 1861800328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415884) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.029833) |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2020-05-21 |