| NPI | 1962882548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D5494) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 8014319-9921) |
| Enumeration Date | 2015-06-09 |
| Last Update Date | 2024-06-06 |