| NPI | 1043595259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AZ 8251) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3526) |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2011-10-19 |