| NPI | 1063764025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: VA 0401418752) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: SC DGD8524) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2024-02-02 |