| NPI | 1013165067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MO 2008035682) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4475) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 700) | |
| Enumeration Date | 2008-09-03 |
| Last Update Date | 2011-04-19 |