| NPI | 1063522803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OK 4376) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: OK 47) |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: OK 118) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2007-07-08 |