| NPI | 1003358755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: ND 2313) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00202978) |
| Enumeration Date | 2016-11-12 |
| Last Update Date | 2022-07-21 |