| NPI | 1952960486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1002774-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901600148) |
| Enumeration Date | 2019-06-09 |
| Last Update Date | 2022-05-03 |