| NPI | 1013454149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16229) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MD 16229) |
| Enumeration Date | 2017-01-26 |
| Last Update Date | 2019-10-21 |