| NPI | 1982151445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401417286) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9843) |
| 1223G0001X Dentist, General Practice (Licence: KY 9843) | |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2021-09-09 |