| NPI | 1043401268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NM DD3017) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 2007) |
| Enumeration Date | 2007-08-05 |
| Last Update Date | 2011-12-16 |