| NPI | 1912648619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123568) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D011548) |
| Enumeration Date | 2022-04-05 |
| Last Update Date | 2024-10-09 |