| NPI | 1043408735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 0023616) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0023616) |
| 1223G0001X Dentist, General Practice (Licence: TX 0023616) | |
| Enumeration Date | 2007-10-09 |
| Last Update Date | 2015-02-23 |