| NPI | 1861851297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D009557) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.031422) |
| Enumeration Date | 2016-02-12 |
| Last Update Date | 2019-10-31 |