| NPI | 1902321367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2020037677) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60694174) |
| Enumeration Date | 2017-08-07 |
| Last Update Date | 2022-02-01 |