| NPI | 1093866493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AL 4132) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AL 4132) |
| Enumeration Date | 2007-01-15 |
| Last Update Date | 2022-09-27 |