| NPI | 1861973299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS045495) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 34560) |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2025-12-29 |