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 |