| NPI | 1073627295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 5336153-9923) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: UT 53361539923) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2019-12-10 |