| NPI | 1992598882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 14226370-9926) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 14226370-9926) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2025-05-23 |
| Last Update Date | 2025-08-06 |