| NPI | 1881755825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4651) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401411035) |
| 122300000X Dentist (Licence: PA DS036503) | |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: NM DD4651) | |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2023-12-22 |