| NPI | 1902219959 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00204852) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2014017650) |
| Enumeration Date | 2014-06-07 |
| Last Update Date | 2021-10-13 |