| NPI | 1083096788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NV S3-354) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9441702-9922) |
| Enumeration Date | 2015-06-18 |
| Last Update Date | 2021-11-23 |