| NPI | 1083053029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 9927) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0442000185) |
| Enumeration Date | 2013-06-24 |
| Last Update Date | 2025-07-31 |