| NPI | 1023168572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 3542) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 0546) |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2007-07-08 |