| NPI | 1972956647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33368) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040979) |
| Enumeration Date | 2016-07-19 |
| Last Update Date | 2023-01-24 |