| NPI | 1053303644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 34385) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN d11755) |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2021-12-30 |