| NPI | 1962140517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 14070) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1859511) |
| Enumeration Date | 2022-05-24 |
| Last Update Date | 2025-04-14 |