| NPI | 1972899391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA 6100) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: NV 6100) |
| Enumeration Date | 2011-06-23 |
| Last Update Date | 2026-07-23 |