| NPI | 1902297138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: CO 00204652) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT FS4540046) |
| Enumeration Date | 2015-02-10 |
| Last Update Date | 2021-07-12 |