| NPI | 1871832048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10276) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 057300) |
| Enumeration Date | 2013-02-08 |
| Last Update Date | 2019-12-02 |