| NPI | 1912569732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID 5397) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD5114) |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2024-12-16 |