| NPI | 1912421280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 7170) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 10752) |
| Enumeration Date | 2017-07-28 |
| Last Update Date | 2019-08-21 |