| NPI | 1891007225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD5553) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 00201972) |
| Enumeration Date | 2010-07-14 |
| Last Update Date | 2024-01-01 |