| NPI | 1891495958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 11406) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D15171) |
| 122300000X Dentist (Licence: IA DDS-10262) | |
| Enumeration Date | 2023-03-07 |
| Last Update Date | 2025-09-02 |