| NPI | 1972914059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 04649) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 670892) |
| Enumeration Date | 2014-05-12 |
| Last Update Date | 2021-04-27 |