| NPI | 1891956447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: GA DN014107) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 4657) |
| 1223G0001X Dentist General Practice (Licence: NJ DI02378200) | |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2022-03-02 |