| NPI | 1902142722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: FL DN22644) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: LA 19121) |
| 1223P0300X Dentist, Periodontics (Licence: LA 6475) | |
| Enumeration Date | 2012-12-26 |
| Last Update Date | 2025-12-11 |