| NPI | 1003338740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 06058801) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022393) |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2023-04-05 |