| NPI | 1073804001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 9246474) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: ID D-4480-PD) |
| Enumeration Date | 2011-04-25 |
| Last Update Date | 2016-02-10 |