| NPI | 1902252752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 10285) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 101533) |
| Enumeration Date | 2016-05-11 |
| Last Update Date | 2019-06-02 |