| NPI | 1972163558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: WV 4416) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WV 4416) |
| 1223G0001X Dentist General Practice (Licence: MD 18847) | |
| 122300000X Dentist (Licence: PA DS045298) | |
| Enumeration Date | 2019-06-17 |
| Last Update Date | 2025-08-19 |