| NPI | 1942647318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TN 10691) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 9521) |
| Enumeration Date | 2013-05-26 |
| Last Update Date | 2018-05-18 |