| NPI | 1962045880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204086) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: CO 204086) |
| Enumeration Date | 2019-10-23 |
| Last Update Date | 2023-11-15 |