| NPI | 1902355456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 10446) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 16158) |
| Enumeration Date | 2016-09-26 |
| Last Update Date | 2023-09-06 |