| NPI | 1881981702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17465) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: VA 2305206991) |
| Enumeration Date | 2011-06-29 |
| Last Update Date | 2026-06-24 |