| NPI | 1063769818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D010986) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412713) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: WA 60294023) | |
| Enumeration Date | 2012-08-11 |
| Last Update Date | 2022-10-04 |