| NPI | 1912370750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN28686) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901021715) |
| Enumeration Date | 2015-11-02 |
| Last Update Date | 2024-01-16 |