| NPI | 1104140201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO 9911) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 24115) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: LA 6085) | |
| Enumeration Date | 2010-03-17 |
| Last Update Date | 2014-03-24 |