| NPI | 1003264508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 9790047-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9790047-9921) |
| 1223G0001X Dentist, General Practice (Licence: UT 9790047-9921) | |
| Enumeration Date | 2016-05-25 |
| Last Update Date | 2026-07-13 |