| NPI | 1962058552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35595) |
| Additional Taxonomies | 122300000X Dentist (Licence: AR 4703) |
| Enumeration Date | 2019-08-10 |
| Last Update Date | 2023-10-19 |