| NPI | 1992377808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1859208) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60952459) |
| Enumeration Date | 2021-07-12 |
| Last Update Date | 2022-04-20 |