| NPI | 1962522532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D8468) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2023-03-28 |