| NPI | 1942795877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2018021980) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401418537) |
| Enumeration Date | 2018-06-23 |
| Last Update Date | 2024-08-15 |