| NPI | 1871106880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11322) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D11322) |
| Enumeration Date | 2020-08-28 |
| Last Update Date | 2021-01-30 |