| NPI | 1992258743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D10265) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10510) |
| Enumeration Date | 2016-07-28 |
| Last Update Date | 2019-04-02 |