| NPI | 1932689726 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 12549) |
| Additional Taxonomies | 122300000X Dentist (Licence: TN 11018) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2018-08-21 |
| Last Update Date | 2024-06-12 |