| NPI | 1023454071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: LA 6422) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO 00201959) |
| Enumeration Date | 2013-05-17 |
| Last Update Date | 2018-11-16 |