| NPI | 1972305159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 0306) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 85138875) |
| Enumeration Date | 2025-03-26 |
| Last Update Date | 2026-07-24 |