| NPI | 1104234632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 31849) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6541) |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2017-02-06 |