| NPI | 1881256766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 9897) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: OR D11696) |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2023-04-10 |