| NPI | 1891358735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2022013911) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 061631) |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2022-07-09 |