| NPI | 1871573402 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1152) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID N-01682) |
| 1223G0001X Dentist, General Practice (Licence: UT 10464104-9921) | |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2021-01-07 |