| NPI | 1962588954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 06749) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NE 5863) |
| Enumeration Date | 2006-10-31 |
| Last Update Date | 2025-09-11 |