| NPI | 1902826407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 3826) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 3826) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 3826) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2020-03-21 |