| NPI | 1972155018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D11073) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-5048) |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2019-07-09 |