| NPI | 1962943423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: DC DEN2001645) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VA 040142013) |
| 1223G0001X Dentist, General Practice (Licence: MO 202003447) | |
| Enumeration Date | 2017-03-17 |
| Last Update Date | 2026-08-19 |