| NPI | 1902466311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00204052) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2021047640) |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2022-02-11 |