| NPI | 1962046268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6001102) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2019037298) |
| Enumeration Date | 2019-10-30 |
| Last Update Date | 2022-12-29 |