| NPI | 1891421947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS045150) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2022029426) |
| Enumeration Date | 2022-07-29 |
| Last Update Date | 2025-08-08 |