| NPI | 1962759324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401414313) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 1856055) |
| Enumeration Date | 2012-08-04 |
| Last Update Date | 2021-07-14 |