| NPI | 1952887762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 11163) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0442000335) |
| Enumeration Date | 2018-07-15 |
| Last Update Date | 2022-03-14 |