| NPI | 1013390228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 10924) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6663) |
| Enumeration Date | 2015-07-07 |
| Last Update Date | 2018-08-16 |