| NPI | 1962853564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SD D1410) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00204006) |
| 122300000X Dentist (Licence: NM DD5145) | |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2024-06-04 |