| NPI | 1073357836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OK 7902) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: OK 7902) |
| 1223P0300X Dentist Periodontics (Licence: OK 7902) | |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: OK 7902) | |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: OK 7902) | |
| Enumeration Date | 2024-06-25 |
| Last Update Date | 2024-06-25 |