| NPI | 1891285003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MD 17145) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041934) |
| Enumeration Date | 2018-05-14 |
| Last Update Date | 2023-08-01 |