| NPI | 1962839092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 8803) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4398) |
| Enumeration Date | 2013-10-03 |
| Last Update Date | 2022-03-25 |