| NPI | 1083107619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: SC 10344) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 10338) |
| 122300000X Dentist (Licence: NC 11064) | |
| Enumeration Date | 2018-06-08 |
| Last Update Date | 2024-01-08 |